Wiki Bleeding Hemorrhoids

[coderguy1939]

Patient came in for colonoscopy with pre-op DX of rectal bleeding. Post-operatively, the doctor's DX was Internal Hemorrhoids, likely source of recent rectal bleeding.

Does the word likely preclude using 455.2 as a DX? ICD-9 guidelines includes "likely" as a qualified DX and not to be coded in an out-patient setting. Does the doctor need to definetively state that hemorrhoids are the source of the bleed?

Thanks.

 

[becka95]

In my experience for profession coding the doctor needs to make the direct link from the rectal bleeding to the hemorroids. If he is still pending tests such as biopsy or a stool test this might be the reason for the use of "likely" and this would not have an impact on coding for the professional.